Summary of findings
Our findings highlight clear differences in the ways in which older people talk about their depression and provides a typology categorising their approach according to their narratives and how their understanding and acceptance of depression underpins this. This underlines a need for flexibility in the help provided to older people with depression and may provide opportunities for health care professionals to improve communication and understanding of how older people make sense of their depression.
Focus on older people’s depression narratives addresses an area known to be a problematic between older people and GPs [
9‐
11,
13]. Older people value talking through their depression over biomedical treatments which may be less acceptable to them [
5,
9,
19]. This study offers a framework to support GPs in understanding the complexities of the narratives older people may bring to consultations which tend to focus on their life story [
10]. The typology here could also be considered for use outside the GP consultation by non-clinical staff, a factor on which importance is placed elsewhere [
9].
This study supports literature suggesting that older people communicate their symptoms in line with their perceptions of depression [
6,
23] and that this can deter them from asking for help [
8,
13,
19]. It builds on evidence showing a need for patients to gain an understanding of their depression including its cause and what has happened to them [
30,
31] so they can explain their experiences to others [
32]. Here, older people’s acceptance of depression was a key influence for what they told GPs, where varying degrees of acceptance were a reason to tell or withhold parts of their story. Some struggled to recognise depression in themselves, typically denying or attributing it to something else (Superficial Acceptors), others were open to accepting it but needed to make sense of what had happened to them first (Striving to Understand) whereas those who had accepted it appeared to have reached an impasse and saw no way of progressing (Unable to Articulate). The resulting patterns of storytelling may indicate a way for GPs to open a dialogue with older people about help they would find acceptable rather than relying on them reporting symptoms.
Parallels can be found between this study and the work of others dating back as far as the 1950s which promotes the importance of the family doctors’ role in building personal relationships and understanding the individual [
33‐
35]. These ideas about patient centredness began to redefine the role of the family doctor to recognize the mind and body as inextricably linked with the patient’s individuality at its core.
“to restore the primacy of the person, one needs a medicine that puts the person in all his wholeness in the center of the stage and does not separate the disease from the man, and the man from his environment.” ([
35], p., 910]).
The findings of this study, particularly that the meaning of depression for older people and the way they communicate about it is built around their life contexts, echo these ideas and suggest they could be revisited by primary care health professionals in consultations with older people.
For McWhinney (1975) this is manifest in achieving a friendship-like relationship with personal knowledge [
36], knowing the person both in good and ill health, treating the person before the illness so that the doctor gains understanding of the patients’ perceptions of their condition and what it means to them [
37]. Evidence in the field often features the perspectives of clinicians and practice staff [
11,
13,
14,
37,
38] whereas the focus of this study is solely the patient and their perspectives and may serve to enhance communication between patients’ and physicians so that their personalized life story is recognised. McWhinney proposes that achieving understanding on a personal level between patient and physician can “lead to quicker and more accurate diagnoses and more effective treatment” ([
35], p., 910]) even though doctors have less time to listen and patients have higher expectations and make more demands of their physicians [
37]. Evidence here which exposes how older patients both make sense of their depression and create meaning may be of value to GPs and other health professionals who spend more time with older patients.
It has been noted that recognising depression and articulating it can be challenging for older people who instead may describe a change in their sense of self in the context of their life stories [
10]. Similarly, the life stories of participants in this study were integral to their constructions of depression, where their accounts would give insight into their experience of having depression. Identification of depression in clinical guidance is based on questionnaire scoring systems and identification of symptoms and may rely on the patient’s willingness to verbalise these and the extent to which they can articulate their narratives to GPs [
39,
40]; this may not be suitable for all patients especially if they struggle to communicate about their depression in a clinical setting. This gold standard approach does not take into account the way older people conceptualise, accept and articulate depression which are the three main factors shown in this study to influence the way they communicate their depression to GPs. Opportunity could be found here for debate or reflection on the one size fits all approach taken in the guidance, which by the very nature of standardization is unavoidable.
This tension between standardisation and personalisation also points to a need for an approach which fits with older people’s ways of communicating about depression rather than expectations for them to report clinical symptoms. Confronting this may be daunting for GPs who may have little time to explore patients’ narratives in depth [
41]. Likewise, their perspectives on managing older people with depression can be characterised by negativity when they have a lack of confidence in their expertise and tend to focus on problems and barriers [
13,
37,
38]. They may also view depression as a consequence of patients’ life circumstances for which they cannot offer change and for which the treatments they can offer are limited in their effectiveness [
42,
43]. The low response rate of 3 practices out of 169 agreeing to take part in the study could be a reflection of these factors. Development of approaches outside the GP consultation that fit with older people’s ways of communicating are in their infancy [
9] but a lack of available services for older people means a time saving method of doing this that considers the demands of working in general practice could potentially support GPs.
The impact of stigma and assumptions about others’ views of depression may also act as a barrier to dialogue between older people and GPs [
9,
10,
19]. Feeling a responsibility to avoid burdening other people has been recognised in those with depression [
10,
19] where not taking responsibility to look after oneself is perceived by people with depression as a personality flaw or a reason to look down upon others with depression. Reluctance to “be a burden” (P13) prevented older people in this study from sharing their depression with family, friends and GPs and instead internalising it. During interviews the Striving to Understand category were responsive to probing and challenging whilst constructing their ideas, suggesting this stage of depression may be an opportunity to challenge these barriers. With suicide among older people estimated to be the tenth most common cause of death in the older population worldwide by 2020 [
44,
45] the need to confront this perception is timely.
Strengths and limitations
The typology is based on participants’ accounts of past episodes of depression or coming out of a recent episode so were likely to be recounting views with hindsight. Some described their depression as severe or mild but in the end this did not shape categories in the typology. While not being generalisable the study is potentially transferrable to other similar contexts and settings.
GPs recruited patients at their discretion and it was not known if a formal diagnosis of depression had been made. This method of recruitment was feasible within the research ethics framework as opposed to recruiting participants without a known diagnosis. Participants talked about their condition using a range of vocabulary. We recognise that older people who have not been given a diagnosis may talk about their condition and experiences differently to those who have, as they have not been given a label for their condition. Exploration of the impact of a diagnosis or no diagnosis on ways older people talked about depression was therefore not possible within the study design.
Data collection and analysis was undertaken by the lead author from a non-clinical perspective. This may have been valuable for patients who find it difficult to express their feelings to GPs and for addressing problems between older people and GPs relating to a condition that has become progressively more medicalised among older people who may see it as a non-medical problem.
The approach here is an unusual attempt to explore patients’ views with minimal influence or bias from the clinical setting or context, using methods that allow patients to lead the development of ideas in the data. Reporting older people’s perspectives in isolation underlines the importance of their voice being heard and allows an in-depth account of ways they communicate about depression.
Implications for practice and research
This study raises the question, what help do older people need for their depression? The findings indicate that older people need flexible support depending on how they conceptualise depression and the extent to which they can articulate their problems and needs. Implications here are for a personalised approach to listening and decoding older people’s narratives about depression that recognises the importance of their situational and life contexts.
Future work is needed to develop strategies for GPs to quickly identify appropriate help for older people with depression that better fits with how they frame and talk about it and which also recognises the demands of general practice. Observations of GP consultations to consolidate the typology groups and further exploratory work to confirm acceptable support for each typology category is required. A model showing appropriate support for different categories of older people in the typology may have implications for other clinical and non-clinical practitioners, or others older people talk to, who may be able to listen for patterns in older people’s depression narratives and offer support, advise or signpost older people to getting the help they need.